急診自我傷害病人特徵與急診醫療花費之現況

Characteristics and medical cost of self-harm patient in emergency department

謝鈞帆(Chun-Fan Hsieh)

指導教授 ： 蕭妃秀

國立臺灣大學/醫學院/護理學研究所/碩士(2022年)

https://doi.org/10.6342/NTU202200306

摘要

研究背景：根據文獻回顧顯示，自我傷害行為對於後續自殺企圖的預測是一個重要因子，其人口學特性在性別、年齡、自我傷害行為及醫療花費上有不同的差異。多數自我傷害行為會至急診就醫，目前針對急診自我傷害病人相關的研究，多集中在歐美國家居多，因此期待能藉由本次研究瞭解國內急診室自我傷害就診病人的特性與現況。
研究目的：瞭解北部某醫學中心自我傷害病人於急診的就診現況，探討其人口學特徵、使用自我傷害的方式差異、反覆使用急診的自我傷害病人現況，並對於自我傷害事件導致的急診醫療花費與急診留觀時間進行分析。
研究方法：本研究以回溯性研究設計（Retrospective design）。使用醫院病歷數據資料庫，收集台灣北部地區的一家醫學中心的急診室，由2017年1月1日至2019年12月31日，共3年的時間中，因自我傷害行為至急診就診之病人為研究對象。收集資料中，對自我傷害病人特性、自我傷害方式、自我傷害導致之醫療花費與自我傷害的反覆就醫情形等三大方向進行資料整理，分析人口學特性、自我傷害行為特徵、醫療費用及急診留觀時間的情況。
研究結果：性別方面：女性自傷比例多於男性，佔68.5%，但是男性有較高的比例使用高致命物理性的方式進行自我傷害(x²=22.071，p<0.001)。相較女性自傷病人，男性自傷病人平均年齡較高、有慢性疾病、使用酒精及娛樂性藥物、出現壓力源以健康、工作、經濟壓力問題為主、較少有至精神科門診就醫的紀錄；女性則有過去精神疾病(憂鬱症、人格疾患)、過去精神科門診就醫紀錄、過去有自傷經驗的比例較高。年齡方面：自我傷害在青少年(12-19歲)佔10.5%、青年(20-39歲)佔49.4%、中年(40-59歲)佔29.6%、老年(大於60歲)佔10.5%；青少年及老年族群容易有自殺意念(x²=17.537，p<0.001)；青少年及青年族群切割傷比例高(x²=23.506，p<0.001)，中年及老年族群多服用藥物及化學物質的自我傷害方式(x²=33.088，p<0.001)。除了年齡和性別，使用藥物及化學物質自傷病人特徵：有婚姻關係(x²=18.547，p<0.001)、有過去慢性病史(心血管疾病、糖尿病)的比例較高(x²=12.448，p<0.001)。使用切割傷自傷病人特徵：有人格疾患(x²=10.308，p=0.001)、曾有自我傷害經驗的比例較高(x²=9.708，p=0.002)。使用低致死物理性自傷病人特徵：有思覺失調症(x²=8.331，p=0.004)、創傷症候群(x²=4.256，p=0.039)、其他精神疾病(x²=7.286，p=0.007)、有過去精神科住院的比例較高(x²=14.171，p<0.001)。合併化學(藥物和化學物質)及物理性自傷病人特徵：有精神科門診的比例較高(x²=7.146，p=0.008)。多數病人都有壓力源導致自傷行為，且以家庭關係為主的比例最多，佔34.3%。反覆自我傷害比例約10.7%，三年平均反覆自傷次數為2.8次。容易出現反覆自我傷害特徵：青少年及中年族群(x²=23.202，p<0.001)，有精神疾病：憂鬱症(x²=31.369，p<0.001)、躁鬱症(x²=32.433，p<0.001)、人格疾患(x²=79.629，p<0.001)、精神科住院(x²=47.729，p<0.001)和精神科門診紀錄(x²=55.609，p<0.001)、曾有過去自我傷害經驗(x²=151.42，p<0.001)。本研究自我傷害病人平均健保花費約為新台幣6,218.39元，一般自付額度約為新台幣502.64元，部分負擔額度約為新台幣451.54元，自我傷害病人平均留觀時間約12.27小時。研究發現男性(t=4.026，p<0.05)、有慢性疾病(t=5.006，p<0.05)有較高的健保總價花費。男性(t=3.116，p<0.05)、服用藥物及化學物質(t=5.607，p<0.05)之自我傷害病人有較長的急診留觀時間。有切割傷的病人有較高的部分負擔費用(t=2.283，p<0.05)。
研究結論：本研究發現性別與年齡是重要的相關因子。不同性別須使用不同介入措施。例如男性容易使用高致死物理性自傷，應積極追蹤病人後續治療狀況，對於物質使用的問題應協助轉介藥酒癮戒治門診，對於壓力源的因應須提供心理和社會支持的介入，以減少自傷行為的發生。女性須協助面對過去精神疾病並提升婚姻幸福感，已預防自我傷害行為的發生。年齡分面，青少年(12-19歲)族群是未來自我傷害的潛在族群，容易有人際壓力、自殺意念和反覆自傷，對於後續社會及經濟的影響是潛在風險，需要連結校園、家庭、醫院三方的資訊及資源，達到早期發現、早期預防與治療。青年族群(20-39歲)以感情及工作方面的壓力為主，提供就業輔導與情感諮商有其必要性，並協助建立較彈性的壓力因應技巧；中年族群(40-59歲)主要的壓力源自家庭問題，除了給予藥物正確使用方法及衛教，必要時需安排家庭諮商的介入以減少家庭內的摩擦，並且減少反覆自傷的狀況；老年(大於60歲)族群雖然比例較低，但是慢性疾病帶來的健康問題與較高的自殺意念，且容易被忽略而導致自殺成功，依據Erikson人格發展理論，此時期的病人因為體力、心理、健康的每況愈下，容易產生對絕望感的心理衝突，因此加強老年族群的身心健康及社會支持，並且協助病人進行自我調適。本研究發現不同的自我傷害方式其病人特徵、醫療花費與急診留觀時間皆不同。自傷防治需針對服用藥物及化學物質自我傷害的高風險族群，例如中年及老年且有慢性疾病者，提供心理與醫療方面的建議或是相關病友會，協助病人面對自身疾病與提升自我照護能力、自尊，並減少無望感，同時請家人協助藥物和化學物質(清潔劑、農藥)的管理，以避免憾事發生，才能降低健保花費與急診留觀時間。自傷防治針對使用切割傷的高風險族群，例如青少年及青年且有自我傷害經驗者，應針對不同的壓力源給予關心與介入，協助建立更有彈性的壓力因應技巧，減少反覆自傷的狀況。自傷防治針對低致死物理性自傷的高風險族群，例如有精神病史和住院史者，鼓勵病人持續治療並給予肯定，協助病人能覺察自己，學習保持疾病症狀穩定。

關鍵字

自我傷害行為 ； 自我傷害特徵 ； 急診 ； 留觀時間 ； 醫療花費

並列摘要

Background: Self-harm behavior is an important predictor of suicide attempts, and its characteristics vary by gender, age, self-harm behavior, and medical costs. Most self-harm behaviors lead to emergency treatment, but the researches about self-harm in Taiwan emergency department are few. Therefore, we hope to understand the characteristics and current condition of self-harm behavior in ED in Taiwan.
Object: To understand the current situation of self-harm patients in the emergency department in a medical center from the north of Taiwan, and to explore their demographic characteristics, difference method of self-harm, the current situation of repeated self-harm behavior in ED, and to analyze the medical costs and observation time in ED caused by self-harm events.
Methods: This is a retrospective designed study. Using a database from hospital medical records and selected all self-harm patients in ED of a medical center in northern Taiwan for 3 years, from January 1, 2017 to December 31, 2019. In the collection of data, we focus on characteristics of self-harm patient, self-harm methods, medical costs caused by self-harm and repeatedly visited of self-harm behavior in the ED, and to explore their demographic characteristics, self-harm behavior characteristics, medical costs and observation time.
Study results: Different gender lead to different characteristics of self-harm. In the proportion of self-harm, female (68.5%) is higher than male, but male is more likely to use high lethal physical self-harm methods(x²=22.071，p<0.001). In average, male is older than female, usually have chronic diseases, and prone to use alcohol and recreational drugs, also have stress from health, work, and financial problem, but they are rare to seek help from psychiatric clinics. The female has a higher proportion of past medical illness (depression, personality disorder), and psychiatric clinics record, and past self-harm experience. Self-harm in the teenager (12-19 y/o) 10.5%, young adult (20-39 y/o) 49.4%, middle-aged (40-59 y/o) 29.6%, and the elder (over 60 y/o) 10.5%. Teenagers and the elder are prone to have suicidal ideation(x²=17.537，p<0.001), teenagers and young adults are prone to use cutting(x²=23.506，p<0.001), middle-aged and the elder are prone to poisoning(x²=33.088，p<0.001). The characteristics of poisoning (drugs and chemicals): marriage(x²=18.547，p<0.001), chronic disease(x²=12.448，p<0.001). The characteristics of cutting: Personality disorder(x²=10.308，p=0.001), and past self-harm experience(x²=9.708，p=0.002). The characteristics of low lethal physical self-harm: Schizophrenia(x²=8.331，p=0.004), PTSD(x²=4.256，p=0.039), other psychotic disease(x²=7.286，p=0.007), and past psychiatric inpatient record(x²=14.171，p<0.001). The characteristic of combine poisoning and physical self-harm is psychiatric outpatient record(x²=7.146，p=0.008). Most of the patients had stress leading to self-harm, and family relationship (34.3%) was the most. The proportion of repeated self-harm is 10.7%, and the average times of repeated self-harm within 3 years is 2.8. The characteristics of repeated self-harm: teenagers and the middle-aged(x²=23.202，p<0.001), Depressive disorder(x²=31.369，p<0.001), Bipolar disorder(x²=32.433，p<0.001), Personality disorder(x²=79.629，p<0.001), psychiatric inpatient record(x²=47.729，p<0.001), psychiatric outpatient record(x²=55.609，p<0.001), and past self-harm experience(x²=151.42，p<0.001).The average health insurance cost of self-harm patient was 6,218.39 TWD, and average registration fee is including self-payment and partial fee. The average self-payment was 502.64 TWD. The average partial fee was 451.54 TWD. The average observation time was 12.27 hours. Males(t=4.026，p<0.05), and patient has chronic disease(t=5.006，p<0.05) had higher health insurance cost. Poisoning patient (t=5.607，p<0.05) had longest observation time. Cutting patient had higher partial fee(t=2.283，p<0.05).
Conclusion: This study found that gender and age were correlated with self-harm. Different gender required different interventions. For example, males are prone to use high lethal physical self-harm, alcohol and illegal drugs, so it is necessary to follow up treatment, psychiatric outpatient department, and addiction clinics. Mental and social support should be provided for males to coping with stress. Keep psychiatric disorder in stable and improve marital well-being are the most important for female self-harm patient. In terms of age, the teenagers (12-19 y/o) are prone to have interpersonal stress, suicidal ideation, and repeated self-harm, and it is necessary to connect the information from school, family, and hospital, to early detect, early prevent and cure. Young adult (20-39 y/o) usually had stress from work and love issue, so employment and relationship counseling should be provided, and help to build flexible coping skills. Middle-aged (40-59 y/o) usually had stress from family issue, so we need family counseling to reduce conflict within family. The elder (over 60 y/o) usually had health problems and high suicidal ideation. The prevention for poisoning should focus on middle-aged and elder patient who has chronic disease. Give psychological and medical advice and help patient live with the disease. Family should support patient and assist in the management of drugs and chemicals. The prevention for cutting should focus on teenager and young adult who has past self-harm experience. Caring and medical intervention is needed to establish flexible coping skills. The prevention for low lethal physical self-harm is stable psychiatric disease.

並列關鍵字

Self-harm behavior ； Self-harm characteristics ； Emergency department ； Observation time ； Medical cost

參考文獻

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